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HCC Crash CourseAbsorbing the Impact
Barbara L. Hays, CPC, CPCO, CPMA, CRC, CPC-I, CEMC, CFPC, FELLOW
Samuel L. Church, MD, MPH, CPC-A, CRC, FAAFP

Disclaimer
The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.
The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.
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For the last 20 years, Barbie has worked alongside physicians
in non-clinical roles of support. Her experiences include front
office management, billing and coding, and practice
management. She has worked with physicians in small
independently-owned settings, large group practices, and
hospital-owned clinics. She enjoys speaking with physicians,
determining their needs, and working with them to make their
documentation withstand the rigors of todays complex
guidelines. She has extensive experience with multiple
specialties, providing audit and coding training to physicians.
Barbie is credentialed through the American Academy of
Professional Coders as a Certified Professional Coder,
Certified Professional Medical Auditor, Instructor, and
Evaluation and Management Coder. She joined the AAFP
team in 2015 as the Coding and Compliance Strategist.
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Samuel Le Church is a private practice rural family physician in Hiawassee, GA, where he lives on a small farm with his wife and four children. He continues to enjoy going to work, both in the office and hospital. He is active with the Georgia Academy of Family Physicians, serving on their Legislative Committee and Board. In addition, he serves as adjunct faculty for 3rd year medical students, who help keep his passion for medicine alive. His practice is recognized as a Level 3 NCQA Patient Centered Medical Home. Dr. Church also serves as Alternate Advisor to the AMA CPT Editorial Panel for the AAFP. In addition, he is a regular speaker and volunteer consultant on practice management, work flow, coding optimization, and chronic care management implementation. He is an AAPC Certified Risk Adjustment Coder. Dr. Church was recently named Georgia Family Physician of the Year.
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Learning Objectives
What you need to know and why about
HCC coding
Plot an HCC map using common primary
care conditions
Practical application from a member
physician perspective
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Background
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http://www.aafp.org/practice-management/payment/coding/icd10-increased-specificity.html
Need to know more about ICD-10 coding? The AAFP hosted a webinar in December 2016 to help you.
http://www.aafp.org/practice-management/payment/coding/icd10-increased-specificity.html

Most Common HCC Groups
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Why do I care? MA is growing.
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Use your words
and specific
diagnosis codes
to tell the story!

All Hail the King
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E11.9
Type 2 without
complications
Value .118
E11.65
Type 2 with
hyperglycemia
Value .368
E11.00
Type 2 with coma
Value .368

Clicks Can Matter
Make it count
Status codes (amputations, old MI, ostomy, etc.)
Underlying conditions
Be leary of
Conditions not specifically
addressed
Careful of cut & paste
Historical (resolved) dxs
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Calculated Annually Beginning

M.E.A.T.
Monitor - signs, symptoms, disease progression, disease regression
Evaluate - test results, medication effectiveness, response to treatment
Assess - ordering tests, discussion, review records, counseling
Treat - medications, therapies, other modalities
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Common Primary Care Encounters
Patient with DM II presents for routine
follow-up. A1C 8.3. Also has stable COPD,
oxygen dependent. O2 DME papers signed
earlier this year.
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Which road to take?
ICD-10 Description RAF
J44.9 COPD .328
E11.9 DM Unspec .118
Total risk= .446
J44.9 COPD .328
Z99.81 Oxygen Dep
J96.11 Chronic Resp Failure w/ hypoxia
.318
E11.65 DM w/ hyper-glycemia
.318
Total optimized risk= .964
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68 y/o patient with hypertension and
hyperlipidemia and BMI 37.2. Has been
using CPAP for years.
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Which road to take?
I10 Hypertension
E78.5 Hyperlipidemia
G47.33 Sleep Apnea
Total risk= .000
I10 Hypertension
E78.5 Hyperlipidemia
G47.33 Sleep apnea
Z68.37 BMI 37.0-37.9
E66.01 Morbid Obesity .273
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Patient with diabetes and polyneuropathy. Right great toe amputated several years ago. He continues to smoke. Patient brought in multiple records from other providers. In addition to refill of meds, you counseled for 5 minutes regarding smoking cessation. You spend 35 minutes reviewing and summarizing the outside records and include that in the visit note.
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Which road to take?
E11.9 DM Unspec .118
F17.219 Nicotine dep/cig
Total risk= .118
E11.41 DM w/ polyneuropathy
.318
F17.419 Nicotine dep/cig
Z89.412 Acquired loss L great toe
.588
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Patient with HTN comes in for upper
respiratory infection. Remote history of
colon cancer and now has a chronic
colostomy bag. DME orders signed earlier
in the year.
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Which road to take?
J06.9 Upper Respiratory Infection
I10 Hypertension
Total risk= .000
J06.9 Upper Respiratory Infection
I10 Hypertension
Z93.3 Colostomy status
.651
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76 y/o presents with swelling of the left arm,
redness, and pain. He takes warfarin for
atrial fibrillation. He is also a liver transplant
patient. Given IM ceftriaxone. PT/INR and
CBC ordered.
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Which road to take?
L03.114 Cellulitis of L upper ext
I48.91 Unspec afib .295
Total risk= .295
L03.114 Cellulitis of L upper ext
I48.2 Chronic afib .295
Z79.01 Long term anticoagtherapy
Z97.4 Liver transplant status
.891
Total optimized risk= 1.186
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Patient for follow-up of major depression,
improving. New med started 6 weeks ago.
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Which road to take?
F32.9 Major depression, single, unspec
Total risk= .000
F32.1 Major depression, single episode, moderate
.330
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To Prevent a Crash
Use documentation and coding to capture
the severity of illness/risk of high cost
Make sure that you capture the complexity
of the patient
Major issues need to be captured at least
once a year (clock restarts Jan. 1)
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Questions
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Resources
Coding Resources
For questions and feedback, contact: Barbie Hays,
Coding and Compliance Strategist,
[email protected]
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http://www.aafp.org/practice-management/payment/coding/code-accurately.htmlmailto:[email protected]

Reference Slides:
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Abbreviations
RAF-Risk adjustment factor (think RVU but sliding scale)
RVU-Relative value unit
HCC-Hierarchical condition classification
MA plans-Medicare Advantage plan
RADV-Risk adjustment data validaton
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Types of models
HHS HCC Health and Human Services Hierarchical Condition Category
CDPS Medicaid Chronic Illness and Disability Payment Systems
DRG - Diagnosis Related Groups Inpatient
ACG Adjusted Clinical Groups Outpatient
CMS HCC Medicare Hierarchical Condition Category, Part C
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Definitions & Terms
Types of Reviews: Retrospective
Concurrent
Prospective
Risk Adjustment: aligning payment and b

hcc crash course - aafp.org · pdf filehcc crash course absorbing the impact barbara l. hays,...

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